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Hollander EM, van Tuinen EL, Schölvinck EH, Bergman KA, Bourgonje AR, Gracchi V, Kneyber MCJ, Touw DJ, Mian P. Evaluation of Dosing Guidelines for Gentamicin in Neonates and Children. Antibiotics (Basel) 2023; 12:antibiotics12050810. [PMID: 37237713 DOI: 10.3390/antibiotics12050810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Although aminoglycosides are frequently prescribed to neonates and children, the ability to reach effective and safe target concentrations with the currently used dosing regimens remains unclear. This study aims to evaluate the target attainment of the currently used dosing regimens for gentamicin in neonates and children. We conducted a retrospective single-center cohort study in neonates and children receiving gentamicin between January 2019 and July 2022, in the Beatrix Children's Hospital. The first gentamicin concentration used for therapeutic drug monitoring was collected for each patient, in conjunction with information on dosing and clinical status. Target trough concentrations were ≤1 mg/L for neonates and ≤0.5 mg/L for children. Target peak concentrations were 8-12 mg/L for neonates and 15-20 mg/L for children. In total, 658 patients were included (335 neonates and 323 children). Trough concentrations were outside the target range in 46.2% and 9.9% of neonates and children, respectively. Peak concentrations were outside the target range in 46.0% and 68.7% of neonates and children, respectively. In children, higher creatinine concentrations were associated with higher gentamicin trough concentrations. This study corroborates earlier observational studies showing that, with a standard dose, drug concentration targets were met in only approximately 50% of the cases. Our findings show that additional parameters are needed to improve target attainment.
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Affiliation(s)
- Esther M Hollander
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Eline L van Tuinen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Elisabeth H Schölvinck
- Department of Pediatric Infectious Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Klasien A Bergman
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Valentina Gracchi
- Division of Pediatric Nephrology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Peadiatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital Groningen, University Medical Center Groningen, University of Groningen Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute for Pharmacy, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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D'Agate S, Musuamba FT, Jacqz-Aigrain E, Della Pasqua O. Simplified Dosing Regimens for Gentamicin in Neonatal Sepsis. Front Pharmacol 2021; 12:624662. [PMID: 33762945 PMCID: PMC7982486 DOI: 10.3389/fphar.2021.624662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The effectiveness of antibiotics for the treatment of severe bacterial infections in newborns in resource-limited settings has been determined by empirical evidence. However, such an approach does not warrant optimal exposure to antibiotic agents, which are known to show different disposition characteristics in this population. Here we evaluate the rationale for a simplified regimen of gentamicin taking into account the effect of body size and organ maturation on pharmacokinetics. The analysis is supported by efficacy data from a series of clinical trials in this population. Methods: A previously published pharmacokinetic model was used to simulate gentamicin concentration vs. time profiles in a virtual cohort of neonates. Model predictive performance was assessed by supplementary external validation procedures using therapeutic drug monitoring data collected in neonates and young infants with or without sepsis. Subsequently, clinical trial simulations were performed to characterize the exposure to intra-muscular gentamicin after a q.d. regimen. The selection of a simplified regimen was based on peak and trough drug levels during the course of treatment. Results: In contrast to current World Health Organization guidelines, which recommend gentamicin doses between 5 and 7.5 mg/kg, our analysis shows that gentamicin can be used as a fixed dose regimen according to three weight-bands: 10 mg for patients with body weight <2.5 kg, 16 mg for patients with body weight between 2.5 and 4 kg, and 30 mg for those with body weight >4 kg. Conclusion: The choice of the dose of an antibiotic must be supported by a strong scientific rationale, taking into account the differences in drug disposition in the target patient population. Our analysis reveals that a simplified regimen is feasible and could be used in resource-limited settings for the treatment of sepsis in neonates and young infants with sepsis aged 0–59 days.
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Affiliation(s)
- S D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - F Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - E Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Centre Hospitalier Universitaire, Hôpital Robert Debré, Paris, France
| | - O Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
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Mfoafo KA, Omidian M, Bertol CD, Omidi Y, Omidian H. Neonatal and pediatric oral drug delivery: Hopes and hurdles. Int J Pharm 2021; 597:120296. [PMID: 33524524 DOI: 10.1016/j.ijpharm.2021.120296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The neonatal and pediatric populations have long been neglected concerning the development of oral dosage forms. For close to two decades, caregivers have had to adjust the doses of the off-label medicines and drugs for adults to suit the neonatal and pediatric needs. This is due to the lack of rules and regulations regarding neonates and pediatrics clinical trials while pharmaceutical industries see this as a non-lucrative approach. Despite such limitations, the administration of solid and liquid dosage forms to neonates and pediatrics necessitates the development of new technologies and even new strategies to meet the needs. Current approaches have not only focused on the development of suitable dosage forms but also the advancement of devices to enhance drug administration to pediatrics and neonates. Though current approaches have significantly added to the number of pediatric and neonatal oral dosage formulations on the market, there is still more room for improvement(s). While novel dosage forms including multiparticulates, orodispersible tablets/films, and chewable tablets have extensively been researched, some administration devices (e.g., nipple shield, pill swallowing cup, and solid dosage pen) have also been explored. Although a few of these products are in the market, the concerted efforts of regulation administrative bodies, pharmaceutical industry settings, and scientists in academia have been oriented to address all issues and advance the neonatal and pediatric-centric pharmaceutical products.
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Affiliation(s)
| | | | | | - Yadollah Omidi
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Hossein Omidian
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA.
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Arora V, Strunk D, Furqan SH, Schweig L, Lefaiver C, George J, Prazad P. Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience. J Neonatal Perinatal Med 2020; 12:301-312. [PMID: 30932898 DOI: 10.3233/npm-180075] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neonatal antibiotic use is associated with a greater risk of nosocomial infection, necrotizing enterocolitis, and mortality. It can induce drug-resistant pathogens that contribute to increased neonatal morbidity/mortality, healthcare costs, and length of stay. Prior to the antibiotic stewardship program, decisions to obtain blood cultures and empiric antibiotics for possible Early-onset Sepsis (EOS) in late preterm and term infants upon NICU admission were provider-dependent rather than algorithm-based. We aimed to decrease empiric antibiotic prescription from 70% to 56% (20% decrease) in infants ≥34 weeks gestation admitted to the NICU. METHODS The stewardship initiative comprised the following practice changes: (1) use of the Neonatal Sepsis Risk Calculator (SRC); and (2) a 36-hour time-out for prescribed empiric antibiotics. Data was retrospectively collected and analyzed for inborn infants pre-intervention (January 2015-December 2015; n = 263) and post-intervention (August 2016-September 2017; n = 279). Data regarding compliance with the new antibiotic guideline were collected and disseminated to the team every week. Overlap between CDC guidelines and calculator recommendations were studied. RESULTS Pre-and post-intervention outcomes were analyzed using chi-square tests. There was a significant post-intervention reduction in the rate of both antibiotic prescriptions (29.4% decline; 70.3% vs. 49.6%; p < 0.001) and sepsis evaluations (24.3% decline; 90.9% vs. 68.8%; p < 0.001). No difference (p = 0.271) in culture-positive EOS cases was observed. There was 92% overlap in blood culture recommendations and 95% overlap between antibiotic recommendations when current CDC guidelines were compared to the SRC. CONCLUSION A significant reduction in antibiotic use and sepsis evaluations was achieved for late preterm and term infants upon NICU admission. No clinical deterioration occurred in post-intervention infants who did not receive antibiotics. There is significant overlap between CDC guidelines and SRC recommendations.
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Affiliation(s)
- V Arora
- Department of Pediatrics, Division of Neonatology, Advocate Children's Hospital, Park Ridge, IL, USA
| | - D Strunk
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - S H Furqan
- Department of Research, Advocate Children's Hospital, Park Ridge, IL, USA
| | - L Schweig
- Department of Research, Advocate Children's Hospital, Park Ridge, IL, USA
| | - C Lefaiver
- Department of Research, Advocate Children's Hospital, Park Ridge, IL, USA
| | - J George
- Department of Pediatrics, Division of Neonatology, Advocate Children's Hospital, Park Ridge, IL, USA
| | - P Prazad
- Department of Pediatrics, Division of Neonatology, Advocate Children's Hospital, Park Ridge, IL, USA
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Hurkacz M, Monika Nowakowska J, Paluszyńska D, Królak-Olejnik B. Individualization of treatment with gentamicin in neonates based on drug concentration in the blood serum. DEVELOPMENTAL PERIOD MEDICINE 2019. [PMID: 30954977 PMCID: PMC8522342 DOI: 10.34763/devperiodmed.20192301.2127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aim: To evaluate how useful it is to make measurements of gentamicin concentrations in newborns' blood in order to optimize antibiotic therapy. PATIENTS AND METHODS Material and methods: 73 newborns empirically treated with gentamicin, in doses consistent with the Neofax® guidelines. There were 152 measurements of maximum and minimum serum gentamicin concentrations. Samples were determined based on the chemiluminescence technique on the Siemens Advia Centaur analyzer. The concentrations of gentamicin that were measured were compared with various therapeutic ranges used in the literature. RESULTS Results: According to the standards adopted in the University Hospital in Wrocław, the maximum concentration was reached in 38.16% of all the children, while the minimum in 26.32%. In other children the concentrations were below or above the therapeutic range. According to the Neofax® guidelines, the intended maximum concentration was observed in 71.05% of the newborns, and the minimum in 32.89%. The minimum concentration of <2 mg/L was found in 93.42% of the newborns, while >2 mg/L was determined in 33.33%, despite a 48-hour dosing interval. These were premature babies (<28th week of gestational age) and 55.56% of them reached a maximum concentration of 5-12 mg/L. There was no significant correlation between maximum or minimum concentration and gestational age or body weight. CONCLUSION Conclusions: 1. The dosage of gentamicin in newborns according to the Neofax® recommendations does not ensure achieving the intended serum antibiotic concentrations. 2. In order to optimize gentamicin therapy in newborns it is necessary to individualize the dose based on measurements of drug concentrations in the blood and pharmacokinetic calculations.
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Affiliation(s)
- Magdalena Hurkacz
- Department of Clinical Pharmacology, Wrocław Medical University, Wrocław, Poland,Magdalena Hurkacz Department of Clinical Pharmacology, Wrocław Medical University Borowska Str. 211, 50-556 Wrocław, Poland phone 601790166
| | | | - Dorota Paluszyńska
- Department and Clinic of Neonatology, Wrocław Medical University, Wrocław, Poland
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Ben Romdhane H, Ben Fredj N, Chaabane A, Ben Aicha S, Chadly Z, Ben Fadhel N, Boughattas N, Aouam K. Interest of therapeutic drug monitoring of aminoglycosides administered by a monodose regimen. Nephrol Ther 2019; 15:110-114. [PMID: 30660586 DOI: 10.1016/j.nephro.2018.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the once-daily regimen of aminoglycosides (AG) is considered as predominantly used by many centers, the level of evidence of Therapeutic Drug Monitoring (TDM) of AG in cases of once-daily has not been clearly defined. The objective of this study is to evaluate the impact of TDM in achievement or maintaining target serum concentrations in patients receiving once-daily administration of AG. METHODS We performed a retrospective analysis of data from patients having received a once daily amikacin or gentamicin and underwent routine TDM. A longitudinal follow up was performed. Data were analyzed according to the adhesion or not to recommendations. A logistic regression was performed in order to evaluate the effect of covariates (age, gender, weight, creatinine clearance [CLcr], TDM-based dose adjustment, weighted dose of AG) on the achievement of non-toxic Cmin. RESULTS A total 437 blood samples issued from 324 patients were analyzed. The cut-off value of Clcr associated with a risk of toxic Cmin was≤41.66mL/min (OR: 11.29; 95%CI: 7.21-17.61; P<0.0001). Eighty-eight patients (27.1%) have at least two sampling points. The univariate analysis showed that the age, weight, CLcr and TDM-based dose adjustment were found to be significant factors in the achievement of non-toxic Cmin. In multivariate analysis, only TDM-based dose adjustment remains a significant factor in the achievement of non-toxic Cmin (OR: 6.66; 95%CI: 2.26-19.63; P=0.0006). CONCLUSION Our study demonstrates the usefulness of TDM-based dosing adjustment of AG antibiotics in achieving nontoxic trough concentrations, particularly in critically ill patients, as they are prone to a renal impairment.
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Affiliation(s)
- Haifa Ben Romdhane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Nadia Ben Fredj
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia.
| | - Amel Chaabane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Sana Ben Aicha
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Zohra Chadly
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Najeh Ben Fadhel
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Naceur Boughattas
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Karim Aouam
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
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Smits A, Kulo A, van den Anker J, Allegaert K. The amikacin research program: a stepwise approach to validate dosing regimens in neonates. Expert Opin Drug Metab Toxicol 2016; 13:157-166. [PMID: 27623706 DOI: 10.1080/17425255.2017.1234606] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION For safe and effective use of antibacterial agents in neonates, specific knowledge on the pharmacokinetics (PK) and its covariates is needed. This necessitates a stepwise approach, including prospective validation. Areas covered: We describe our approach throughout almost two decades to improve amikacin exposure in neonates. A dosing regimen has been developed and validated using pharmacometrics, considering current weight, postnatal age, perinatal asphyxia, and ibuprofen use. This regimen has been developed based on clinical and therapeutic drug monitoring (TDM) data collected during routine care, and subsequently underwent prospective validation. A similar approach has been scheduled to quantify the impact of hypothermia. Besides plasma observations, datasets on deep compartment PK were also collected. Finally, the available literature on developmental toxicology (hearing, renal) of amikacin is summarized. Expert opinion: The amikacin model reflects a semi-physiological function for glomerular filtration. Consequently, this model can be used to develop dosing regimens for other aminoglycosides or to validate physiology-based pharmacokinetic models. Future studies should explore safety with incorporation of covariates like pharmacogenetics, biomarkers, and long-term outcomes. This includes a search for mechanisms of developmental toxicity. Following knowledge generation and grading the level of evidence in support of data, dissemination and implementation initiatives are needed.
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Affiliation(s)
- Anne Smits
- a Neonatal Intensive Care Unit , VU Medical Center , Amsterdam , The Netherlands.,b Neonatal Intensive Care Unit , University Hospitals Leuven , Leuven , Belgium
| | - Aida Kulo
- c Institute of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine , University of Sarajevo , Sarajevo , Bosnia Herzegovina
| | - John van den Anker
- d Intensive Care and Department of Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , The Netherlands.,e Department of Paediatric Pharmacology , University Children's Hospital Basel , Basel , Switzerland.,f Division of Pediatric Clinical Pharmacology , Children's National Medical Center , Washington , DC , USA.,g Departments of Pediatrics, Integrative Systems Biology, Pharmacology & Physiology , George Washington University School of Medicine and Health Sciences , Washington , DC , USA
| | - Karel Allegaert
- d Intensive Care and Department of Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , The Netherlands.,h Department of Development and Regeneration , KU Leuven , Leuven , Belgium
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